STAT+: Health plan formularies lowered barriers to fair access to some drugs, analysis finds
Most of the formularies run by some of the largest health plans in the U.S. generally provide “fair access” to 18 treatments for a handful of serious diseases, a new…
Most of the formularies run by some of the largest health plans in the U.S. generally provide “fair access” to 18 treatments for a handful of serious diseases, although transparent coverage information is often lacking for some medicines, a new analysis has found.
Almost uniformly, the 19 formularies made the medicines available fairly when judged on three criteria: eligibility based on clinical data, restrictions placed on prescribers, and step therapy, which requires patients to try other medicines before an insurer will approve a prescription. The formularies are run by health plans, pharmacy benefit managers, and the U.S. Department of Veterans Affairs.
But only 62% of the formularies scored well on a fourth criteria: cost-sharing, which is the portion of expenses paid by insured individuals. Although there is a caveat worth noting: This particular metric was determined based on a smaller subset of just two medicines that were deemed to be fairly priced based on a cost-effectiveness assessment. Those two drugs were the Nexlizet cholesterol medicine and Benlysta for treating lupus.
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